Medicare Part D Coverage Gap (“Donut Hole”)

Medicare Part D plans have a Coverage Gap, which is a temporary limit on what your drug plan will pay for prescription drug costs. If you do not receive a subsidy such as Extra Help from Medicare, or aren’t enrolled in a plan that offers additional Gap coverage, the combined amount you and your Part D plan spend on your Medicare Part D costs (not including premiums), determines if and when you will reach the Gap. That combined amount is $3,750 (in 2018) and $3,820 (in 2019).

While in the Gap, you will pay 44% of the cost for generic drugs, and 35% of the plan’s cost for brand drugs (in 2018) and 37% of the cost for generic drugs, and 25% of the cost for brand drugs (in 2019). You leave the Gap when you alone (not what the plan spends) spend a total of $5,000 (in 2018) and $5,100 (in 2019). You then enter the ‘Catastrophic Coverage’ stage, where the costs of your prescriptions are usually lower.